1. Decreased cardiac output r / t cardiac malformations.
Goal : Maintain adequate cardiac output
Interventions :
- Observation of the quality and strength of the heartbeat, peripheral pulse, skin color and warmth.
- Assess the degree of cyanosis (circumoral, mucous membranes, clubbing).
- Monitor signs of CHF (anxiety, tachycardia, tachypnea, tightness, fatigue, periorbital edema, oliguria, and hepatomegaly).
- Collaboration therapy in accordance with the order, using the toxicity hazard prevention techniques.
- Give treatment to reduce afterload.
- Give diuretic as indicated.
2. Impaired gas exchange r / t pulmonary congestion.
Goal : Reduce the increased pulmonary vascular resistance
Interventions :
- Monitor the quality and rhythm of breathing.
- Adjust the position of children with Fowler position.
- Avoid the child of an infected person.
- Provide adequate rest.
- Provide optimal nutrition.
- Give oxygen if indicated.
3. Activity intolerance r / t imbalance between oxygen consumption by the body and oxygen supply to the cells.
Goal : Maintaining an adequate level of activity
Interventions :
- Allow the child to rest frequently, and avoid disturbances during sleep.
- Suggest to do the game and light activity.
- Help children to choose activities appropriate to the age, condition and abilities of children.
- Avoid ambient temperature is too hot or too cold.
- Avoid things that cause fear / anxiety in children.
4. Imbalanced Nutrition: less than body requirements r / t fatigue at mealtime and increased caloric needs.
Goal : Maintaining weight gain and height appropriate
Interventions :
- Provide a well-balanced diet, high nutrients to achieve adequate growth.
- Monitor height and weight, is documented in the form of a chart to determine the tendency of growth of children.
- Measure weight every day with the same weight and the same time.
- Record intake and output correctly.
- Give food with small portions but often to avoid fatigue at meals.
- Children who receive diuretics are usually very thirsty, therefore the fluid is not restricted.
5. Risk for infection r / t decline in health status
Goal : Children will not show signs of infection
Interventions :
- Avoid contact with infected individuals.
- Give adequate rest.
- Provide optimal nutritional needs.
6. Psychosocial Assessment include: age of the child, child development tasks, coping used, the child's habits, family response to childhood diseases, family coping and family adjustment to stress.
Goal : Provide support to parents
Interventions :
- Teach family / parents to express feelings of having children with heart defects, discuss treatment plan, and has an important role in the success of the treatment.
- Exploration feelings of parents about the feelings of fear, guilt, grief, and feelings of inadequacy.
- Reduce the fear and anxiety of parents by providing clear information.
- Involve parents in child care while in hospital.
- Give a boost to the family to involve other family members in child care.
Expected Results :
- The child will show signs of improvement in cardiac output.
- The child will show signs of the absence of an increase in pulmonary vascular resistance.
- Children will grow in accordance with the growth curve weight and height.
- Children will retain food and beverage intake to maintain weight and sustain growth.
- Children will not show signs of infection.
- Parents will express his feelings as a result of having a child with a heart defect, discuss treatment plan, and have confidence that parents have an important role in the success of the treatment.
Discharge Planning
- Control the time determined.
- Describe the needs of children activities that can be done in accordance with the age and condition of the disease.
- Teach the skills needed in the home, namely:
- Drug delivery techniques.
- Techniques feeding.
- Measures to address the case of things that are worrying signs of complications, who will be contacted if needed help.